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Treating MS bladder symptoms

Prof Clare Fowler
Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery

Open Door - November 2008 pages 10-11

In February this year a group of interested parties met in London to discuss bladder management of people with multiple sclerosis. The aim was to publish a paper setting out what we thought were reasonable UK guidelines for this condition. The group included representatives from:

  • Association of British Neurologists
  • Association for Continence Advice
  • British Association of Urological Nurses
  • British Association of Urological Surgeons
  • Centre for Research in Primary Care
  • Royal College of Nursing
  • UK MS Specialist Nurse Association
  • MS Trust

Bladder symptoms are very common, affecting about three quarters of people with MS. It is also clear that the severity of bladder troubles is related to the degree of spinal cord malfunction. In other words, the worse someone's walking, the more likely the bladder is to be troublesome and difficult to treat. It, therefore, made sense to consider what treatments should be recommended at different stages of the illness.


Early stages

In people who are walking unaided, or perhaps need one stick, poor bladder emptying is less likely to be a problem and the main symptoms will be urgency and frequency due to an over active bladder. The main effective treatments are oral medications called anti-cholinergics, such as oxybutinin, tolterodine, solifenacin and trospium chloride. These all work by blocking the effect of acetylcholine, the chemical which connects the nerves to the bladder, and so make it less over active. However, these drugs may prevent the bladder emptying effectively and, if MS has already affected the efficiency of bladder emptying, they can make things worse. The group agreed that investigations and treatment should, therefore, follow the scheme shown in Figure 1.

diagram showing effective management of bladder symptoms in the early stages of MS

There is evidence that desmopressin can help manage frequency but this treatment should be used with caution. Pelvic floor exercises may help at this stage if individuals are able to get good pelvic floor voluntary control.

If a person presents with symptoms, the urine should be tested with a dipstick to check for an infection (UTI). The amount of urine left behind after voiding should then be measured (post void residual volume (PVR)) preferably before starting treatment with anti-cholinergics.

In fact this investigation and treatment scheme works well for all stages of the condition as it identifies the problem of incomplete bladder emptying which might otherwise contribute to bladder over activity. There was some discussion about this in particular, because measuring the post void residual volume is a very simple (no tubes!) test that can be done in the individual's home by a continence advisor with a small portable ultrasound machine. We agreed that this gives important information that would not otherwise be available. This was an important point because it means that many people could be correctly and safely managed using only simple, non-invasive tests.


Intermediate stage

If the individual has more difficulty walking, their ability to empty their bladder is likely also to be affected. If so, they need to be taught to perform clean intermittent self catheterisation (CISC) by a urology specialist nurse or continence advisor. This technique should be offered to anyone who is found to have a residual volume of more than 100ml in their bladder. Many people do not find clean intermittent self catheterisation easy and unfortunately there are no highly effective alternatives. There is a buzzing device that can be applied over the bladder and helps some people with incomplete bladder emptying. Pressure on the lower abdomen to empty the bladder (the Crede manoeuvre) is not recommended.

A new treatment that has become available in the last few years is the injection of the bladder wall with botulinum toxin A (Botox). This is a highly effective treatment with very few adverse effects but almost all people with MS who have had it, need to use intermittent self catheterisation afterwards. It is not, therefore, a treatment for somebody who is unwilling to consider doing that. It must be noted, however, that this treatment is not yet licensed either in the UK or elsewhere in Europe and is not available in all centres. It can be done as an outpatient procedure. Using a flexible cystoscope, it takes less than fifteen minutes to inject at about 30 different sites in the bladder wall. It has a surprisingly rapid effect on reducing urinary urgency. This benefit seems to last for about ten months, at which time it has to be repeated. Happily it looks as if it is as effective at the second, third and fourth time as it was at the first.


Advanced stages

If disability worsens and it is no longer possible to use intermittent self catheterisation, but poor bladder emptying remains a problem as well as an over active bladder, an indwelling catheter is the best option. The urologists in the group strongly recommended a supra pubic rather than an indwelling urethral catheter.


Possible urological surgery

Just occasionally some sort of urological surgery might be indicated. It is important to consider stress incontinence in women who have had babies and who leak when they cough or sneeze. In such patients further investigations would be appropriate rather than just measurement of the residual volume. Very rarely urologists would consider a procedure such as an ileal conduit if incontinence remained a major problem and catheters could not work.


Referral to urology services

The group suggested that the indications for urological referral should be:

  • Haematuria - blood in the urine
  • Frequent urinary tract infections
  • Symptoms unresponsive to treatment
  • Consideration for botulinum toxin A injections
  • Long term suprapubic catheter required
  • Rarely, consideration of urological surgery

Urinary tract infections

Urinary tract infections are a real problem for people with MS. Many describe how their MS may deteriorate following an infection of any sort, including a bladder infection. There is some evidence that cranberry drinks may reduce the likelihood of an infection. If genuine infections do occur it is sensible for the individual to see a urologist to check that they have not developed some unrelated trouble such as a bladder stone. However in people doing intermittent self catheterisation it was thought inadvisable to send regular urine specimens to the laboratory since these will always report some sort of bacterial contamination, which is different from a genuine urinary tract infection. It was agreed that should no cause be found but urinary tract infections remain a recurrent problem, the individual should start on a low dose antibiotic.


Conclusion

There was complete agreement amongst the group that everyone with MS experiencing bladder symptoms should be able to be seen and assessed by an expert. Exactly whom would depend on the type of problem. There is no stage of the illness when bladder symptoms should not be attended to and people, or their carers, should ask their GP to refer them appropriately. Individuals should be encouraged to understand the aims of the treatment that has been suggested. Both the MS Trust and MS Society have produced information that helps with this.

At the moment these are merely guidelines but it is hoped that if NICE consider the question of neurological incontinence, that this work will receive some sort of formal endorsement.

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